global health policy issues

Over the holidays, I visited with my sister-in-law and her family who live on the South Pacific island of New Caledonia. Near their home was a lovely beach that we visited on more than a few occasions. About 400 m before the arrival to the beach, there were big signs posted along the side of the road indicating that the region was a tsunami risk zone. When I asked my sister-in-law about the signs, I learned that the signs were just a part of a broader preparedness system that had been put in place since the Indian Ocean tsunami of 2004. Schools had evacuation plans, cell phone alert systems had been created, and other measures had been put in place to prepare for future tsunamis.

Just a few short months before the Indian Ocean tsunami struck in 2004, I had been diving off the coast of Phuket and Ko Phi Phi two areas in Thailand that suffered incomprehensible loss of life during the tsunami. Such signs of preparedness did not exist. Apparently this was a real lost opportunity.

In the early hours of yesterday morning, a colossal earthquake struck off the coast of central Chile, just a few hundred miles outside of Santiago and near many other heavily inhabited cities. While the destruction has been tremendous, a number of factors have contributed to the fact that the loss of human life might be moderate: the quake struck at night, the quake was deep, and perhaps most importantly – Chilean infrastructure has largely been built to withstand earthquakes.

Almost immediately tsunami preparedness plans went into the action across the Pacific region. Hawaii evacuated people from beaches and moved tourists at beach front hotels to higher grounds. Half a million people in Japan were moved to higher grounds. When the waves eventually made it to these far away shores the waves turned out to be smaller than had been predicted, but the key is that it appears as though the region had been prepared to handle the situation had the worst materialized.

I don’t want to draw attention from the grave situation currently unfolding in Chile – it is one of the saddest days for a country that has seen many sad days during its history – but I did want to draw attention to what appears to have been a major success: international efforts to create and implement disaster preparedness plans. This is classic public health in action – when the system works, no one notices. I think it needs to be celebrated.

Chile is a country that shares a very special place in my heart. I spent a month there in early 2004 studying the health reform process that was underway. No single experience has had such a profound impact on my view of the realities of the health policy making process. It was also the place where I experienced my first “moderate” earthquake – about 5.5. However, it happened at night and buildings were so well built that I was the only person I knew who felt it! My thoughts go out to everyone in Chile who has been affected by this earthquake and I wish them all the best for what will surely be a long an difficult recovery process.

We all know that child mortality rates are too high in the developing world and that persistent high levels of infant and under five child mortality are among the greatest failures of global health. However, as important as it is to measure and monitor progress on existing child health indicators, the use of these measures may be overlooking a very important component of child health in developing countries.

Currently the infant mortality rate is defined as deaths within the first year of birth per 1,000 LIVE births. Neonatal births is the number of births within the first month of life per 1,000 LIVE births. And so on… Easy, right?

Whenever I teach my students about the calculation of these measures, eventually someone asks the absolutely right question: what happens if the child is not born alive? That is, what if it is a stillbirth? Easy, it does not count. Yes, if a woman carries a child to near or even full term and for whatever reason the child is born dead that life counts for nothing in our measures of child mortality or in our measurement of burden of disease.

In developed countries, this omission seems to be discussed more in terms of a nuisance factor in the calculation and comparison of infant and other child mortality measures across countries. Even among developed countries, there is no one standard definition of a live birth and it has been speculated (mainly by countries with higher rates of infant mortality) that stringency in this definition might partially explain the differences across developed countries.

In developing countries, however, this omission is much, much more important. It has been estimated that there are approximately 3.3 million stillbirth worldwide every single year. To put this in perspective, it has been estimated that there are roughly 135 million live births per year of which 8.8 million of these children will die before their first birthday. Approximately 40% of those deaths, or about 3.5 million will happen during the first month. Stillbirths thus represent nearly an equivalent loss of life as neonatal mortality. It is huge. Plus, if we were to take these figure into consideration, it would mean that we are underestimating overall child mortality by some rather substantial margin. It has been estimated that if stillbirths were included among deaths, about half of all child mortality would occur before the child should have reached their first birthday.

In most of the international health literature, a stillbirth is frequently defined as the birth of a dead fetus that weighs at least 1000 g to a woman who has been pregnant for at least 27 or 28 weeks, although this definition is not standard in all settings (fetuses born more prematurely than 27 weeks or under 1,000 g are not considered viable births and don’t count as a birth at all). A stillbirth can be antepartum, meaning it took place prior to the onset of labor or it can be intrapartum, meaning that the death took place after the onset of labor. There are approximately 2 antepartum stillbirths for every intrapartum stillbirth globally.

The distribution on child mortality for live births over time kind of looks like the side of a skill hill (yes, I have Olympic fever). Deaths are heavily concentrated in the first few days of life and declining steeply but steadily over time. (OK, this is a gross oversimplification). It is estimated that 75% of neonatal deaths are actually take place within the first week of life, and I am sure a similar pattern would hold within the first week of life as well. So if we really want to target neonatal deaths we need to focus on interventions that take place in the first few days of life, ideally starting during the delivery process.

There are low-cost interventions out there that are thought to improve neonatal outmodes: training in resuscitation, kangaroo care, thermoregulation, immediate breastfeeding, etc. A recent evaluation of a package of these interventions led to a somewhat surprising outcome: the training package had little impact on measures of neonatal mortality, despite showing evidence that coverage of these indicators increased due to the intervention.

After finding this null result, the authors conducted a secondary analysis of their data and showed a marginally significant reduction in the rate of stillborns in the intervention. Although not conclusive, one interpretation of these results is that the intervention may have saved a number of children who would otherwise have been born dead, bringing more marginally unhealthy children alive and thus biasing their measures of neonatal mortality upwards.

What did this study show? One, I think it shows that we still have a lot to learn about what actually improves outcomes of newborns during the first week of life. But as well, I think this study really highlights the arbitrary nature of our standard definitions of live vs. still births. To get a real measure of the human life lost during the late stages of pregnancy and in early life we may really want to capture the loss of children who die just moments before making their entry into the world.

Last week I started the third trimester of my first pregnancy. My baby is a really active little creature, kicking and moving throughout the day – and throughout the night – constantly inflicting pain and damage to my ribs and internal organs. To me, it is very much alive now and I find it disturbing that should something happen between now and when my child takes his first breath on the outside world its death would not count, essentially saying that as a society we do not care. We need to also understand what happens during this important stage of life and what can be done to improve outcomes in the late stages of pregnancy.

Ever wondered about the distribution of mosquito around the world? Ever want to know what the most common species of mosquito where you live? Well look no further – introducing MosquitoMap!

MosquitoMap is: “…is a geospatially referenced clearinghouse for mosquito species collection records and distribution models. Users can pan and zoom to anywhere in the world to view the locations of past mosquito collections and the results of modeling that predicts the geographic extent of individual species.”

I am sure this is an enormously useful tool for people who know and care about this stuff, but I just thought it was pretty nifty for mapping the little buggers. Turns out the distribution of these pests is enormously complex and poorly understood: “It is often erroneously assumed that a great deal is known about mosquito systematics and distributions. One reason is that because of their medical importance mosquitoes have been and continue to be thoroughly studied. This can be said perhaps for the 200 or so vector and pest species, about 80 (out of 460) of which are Anopheles malaria vectors. However, there are about 3500 described species (WRBU Mosquito Catalog; Harbach & Howard, 2007, European Mosquito Bulletin, 23: 1-66), most of which are relatively poorly known. Recently, molecular methods have shown, that many Anopheles vector species belong to morphologically similar or indistinguishable species complexes.”.

Ever since I became aware of the high rates of Cesarean rates in the US (in 1986 when expecting my first child), I have seen it as an indication of how doctors have medicalized birth – seeking greater prestige, less emotionally demanding interaction with patients, and possibly higher fees. Whenever people tell me that doctors do cesareans because women prefer them, I find it laughable. The power relations in the consulting room and the way doctors characterize options has an enormous influence over what patients do or do not want.

In the 1990s, I oversaw a research project in which one of the studies took c-section rates as an indication of corruption – when a private hospital had rates over 70% they claimed it was appropriate given the risks, but the rates were less than half as high in the public hospital with much higher risk population. We suspected that fees and convenience were driving a large part of those high rates.

My view, however, has mellowed considerably since reading an essay by Gawande in the New Yorker. While other procedures may be safer than cesareans in the hands of a skilled midwife or obstetrician, he points out that it is easier to train competent and skilled practitioners in one procedure (c-section) that can be used in many circumstances than to do so for dozens of procedures that apply to different situations (turning a breech birth, forceps delivery, etc.). So while I still believe that cesarean rates are higher than they need to be, I’m aware that in a well-functioning health system, they are not likely to be the last resort emergency procedure that I thought they should be.

1. The Journal “Global Health Governance” has a special call for papers out on “Governance and the AIDS Response”. More details online here.

2. Apply to the second class of the Global Health Corps program. Application information is available here. Applications close for US applicants on March 1 and in April for African/International applicants. More information here.

4. NYU is hosting its annual “Conference on the Health of the African Diaspora” this Friday, February 19, 2010 at the NYU medical campus. It will include interesting talks including a talk by the Minister of Health of Ghana Dr. Benjamin Kunbuor. More information is available here.

The March edition of Health Policy and Planning has a review and a series of commentaries devoted to the topic of scaling up of global health initiatives in health systems. Most of these articles are available free of charge so you might be interested in checking them out (and while you are there – check out the editor’s choice article too!).

1. In a review, Lindsay Mangham and Kara Hanson provide an overview of the literature on the concept of “scaling-up” including an attempt to define the term formally. The authors write:

“We argue that the notion of scaling up is primarily used to describe the ambition or process of expanding the coverage of health interventions, though the term has also referred to increasing the financial, human and capital resources required to expand coverage.”

They then go on to review efforts to analyze and evaluate such initiatives. It is a good overview for those interested in this topic.

2. Lucy Gilson and Helen Schneider discuss how to the political commitment that is required to support the calls to scale-up programs – a missed opportunity.

“Evaluation must now become the top priority in global health. Currently, it is only an afterthought. A massive scale-up in global health investments during the past decade has not been matched by an equal commitment to evaluation. This complacency is damaging the entire global health movement. Without proper monitoring and accountability, countries and donors—and taxpayers—have no idea whether or how their investments are working. A lack of knowledge about whether aid works undermines everybody’s confidence in global health initiatives, and threatens the great progress so far made in mobilising resources and political will for health programmes in low-income and middle-income countries.”

I agree – but be careful of what you wish for: evaluation is a double-edge sword. When good evaluations are done and show evidence of impact it can be one of the most powerful tools to advocate for further investment and program rollout. When evaluations are done that show less than desirable impact than it can mean the end of such initiatives. It is therefore not particularly surprising that many global health initiatives have not made commensurate investments in evaluation – in particular the high profile initiatives that have emerged over the past decade.

Evaluation benefits those programs where our prior belief of effectiveness is lower than its true level of effectiveness. High profile initiatives such as the Global Fund and PEPFAR have been sailing high, enjoying incredible popularity. In short, they have the most to lose from evaluation.

The basic message from this evaluation is that the ACSD program – which previously had been heralded as a great success – likely had little or no impact on focus districts in at least 3 countries in West Africa. The ACSD program’s goal was to rapidly scale up three basic benefits packages thought to be effective against major childhood killers (IMCI+, ANC+, ad EPI+) in 11 countries in West and Central Africa from 2001-2005. Running on what would be considered a barebones budget in today’s terms, the program focused on getting these packages into the communities of focus districts through the use of community workers and other investments in primary health infrastructure. The goal was to reduce child mortality by at least 25% – a previous evaluation conducted by UNICEF suggested that part way into the program the program had already reduced mortality by 20%, although the methods employed were probably not appropriate to make such claims.

Not only did the Hopkins evaluation find no differential impact on child mortality from the ACSD in the focus districts in the 3 countries where they conducted the evaluation, if anything, they found that mortality declined more in non-focus areas. Arguably the program found higher coverage outcomes for some of the indicators in the focus regions, but it is hard to call this strong evidence. Notably, coverage of the one package that targeted the greatest share of total childhood deaths – the IMCI package – did not improve in the focus areas and actually declined in one country.

A few caveats – the evaluation suffered a number of methodological shortcomings, but my sense is that the evaluators did the best they could have done given that there was not a great deal of data available to conduct the analysis and not enough efforts had been made by program implementers to ensure that appropriate data would be available for the evaluations. Plus, the focus districts in each region were not randomly chosen, nor were they chosen using similar criteria in each country, right away setting up a number of challenges to evaluating the outcomes. So while the results of the evaluation must also be interpreted with a grain of salt, the overwhelming lack of evidence of program effectiveness should still be the key takeaway.

So what can be learned from this example? Well, there is a great deal of value in conducting evaluation of global health initiatives but one must also realize that doing more evaluation will not be a boon to all global health initiatives. Overall, it is donors and recipients that will benefit the most (and evaluation groups too!) but that there will be some winners and some losers if evaluation efforts expand. This speaks to the need to a priori establish rules and guidelines to ensure unbiased evaluations. Donors should increase the transparency of their efforts by ensuring that the global health initiatives that they support set up standard evaluation practices and that the results of all of these evaluations – not just the positive ones – are made available to the general public.

Not all evaluations will likely produce such dire outcomes, so I agree, investing in evaluation might be an important strategy to improve and sustain political will for the massive scale up of global health initiatives that has been witnessed during the past decade. Sadly, for such benefits to be seeing impact today – when they are perhaps the most needed – they should have been made years ago. But it is never too late to begin.

Caesarean section (cs) rates in developed countries have grown rapidly over the past few decades, leading to concern among some experts that cs rates of 25-35% might be causing more harm than good to women and driving unnecessary health care expenditures (the US rate is roughly 30%). While it has been known for some time that rates are also high in some Latin American countries, there is a general perception that rates are still low in most developing countries – perhaps even too low. At least that is my perception based on the data I have seen from Sub-Saharan African countries.

I guess that is why it was so shocking for me to learn that rates in many Asian countries are high, potentially as high, as rates seen in Latin America and most developed countries. The results of a multi-country facility-based study of delivery and pregnancy outcomes in Asia has shown that at least a quarter of births delivered in facilities in 9 Asian countries were delivered by Caesarean section – in China nearly one half of births ended in a Caesarean section.

The study was only conducted in facilities, so these should not be taken as national rates. The authors also explored whether or not more intensive births were associated with better or worse outcomes for the mother and baby and found evidence that suggest that if anything these procedures are causing more harm than good (again, these findings should be interpreted cautiously given selection effects due to the facility-based nature of these surveys). But taken together, the overall levels and potential consequences do raise the question of whether cs rates are too high in some developing countries as well?

There are at least three potential explanations as to why rates are so high. First, it might be that women want caesarean sections and are increasingly electing these procedures. The Asia study did not seem to suggest this to be the case as most of the surgeries were done during the intrapartum period with indications. Second, it might be that there has been increased need for the service or new indications for which it is recommended – this again seems a bit unlikely as it is hard to imagine what could possibly explain the rapid increases. Finally, it could be that the physician has a high level of discretionary power over the decision to operate and that due to a number of factors have become more likely to intervene. This seems – at least to me – to be the most likely candidate but of course, I have not seen any good
evidence to support this view.

I really think that studies of this nature point to the urgent need for a better understanding of how women are accessing pre-natal, delivery, and post-natal care – not just in the developing world but everywhere. I am almost 7 months pregnant and am currently trying to develop a plan for my own delivery but end up finding myself frustrated with the lack of evidence that seems to be available to inform my decisions. It is amazing how little we know about a process that has been happening for at least as long as human have been on this earth…

“Many of the most important issues in international health are so completely taken for granted that they are never discussed. We tend especially to have cultural blind spots because we assume that our own values are the international norm and that our way of doing things is automatically right. We become aware of cross-cultural problems only when our personal assumptions are challenged by a clear conflict of values. Only rarely do we review our motivations.”

The above quotation was taken from an editorial article published in 1979 by Carl Taylor, Professor Emeritus of International Health at Johns Hopkins University’s School of Public Health, in the American Journal of Public Health. I came across this article recently and included it in my spring undergraduate NYU course (Global Health: Policies, Politics, and Institutions) reading list because although the article was written over 30 years ago, it is as true today.

I found out this evening (via Twitter) that Professor Taylor passed away earlier this week. I was saddened to hear that the global health community had lost one of its founding fathers. You can read more about Professor Taylor, and his work, especially on the need for local solutions in global health problems, here.

Earlier last week, the findings from two critically important studies on the use of the Rotarix vaccine (produced by GSK-biologicals) to combat rotavirus related diarrhea in the developing world. After prenatal causes and pneumonia, diarrhea is the most important cause of child deaths in the world – accounting for an estimated 16% of under five mortality. Most of the tools to combat the disease – oral re-hydration therapy and clean water and sanitation – have not been adequate to reduce the burden of this seemingly simple condition, perhaps because the needed behavioral response is not so easy after all. The study results overall were very positive, which is really great news, but it also raised a few important caveats which may limits its overall impact in the long run.

Rotavirus is considered to be the single largest cause of diarrhea globally and alone thought to be responsible for upwards of half a million child deaths a year. Six of the seven countries with the highest mortality due to rotavirus are in Africa (can anyone guess the other one?). Vaccines against rotavirus have been introduced in the past – and one has even been withdrawn – but their use has become increasingly common in many middle and high income countries in recent years. The world had been waiting for the results from the studies released last week.

One study, conducted in South Africa, and Malawi demonstrate that when the vaccine is given properly, it reduces all forms of reported diarrhea by about 30% and reduced the incidence of rotavirus induced diarrhea by 60% although the results were much higher in South Africa. There were not major differences in severe events, suggesting that the vaccine was also safe.

But why was there such much lower efficacy in Malawi? The results from this African study suggest that the vaccine is less efficacious in Africa than in other settings where the vaccine has been tested. There is some evidence that live oral vaccine in general tend to be less effective in low income countries, perhaps because they require an in tact and effective immune system to generate a sufficient immune response to provide protective benefits. It is also possible that children in these settings are also already exposed by the time they get the vaccine, making the vaccine seem less effective when studied in trial settings.

Also, the study findings point to a story where the timing of when this vaccine appears to matter quite a bit – not just or the sake of protecting children earlier, but or the sake of avoiding age-dependent risk of developing intussusception, a rare but dangerous side effect which was part of the reason that earlier forms of the vaccines were not expanded to the developing world. There are frequently delays in vaccine timing in many developing countries, so this might represent a real challenge precisely in the countries where it is needed most.

Plus, since this is a live oral vaccine, the cold chain considerations for this vaccine are likely to be much more important than for other forms of vaccines.

The second study, conducted in Mexico, assessed the impact of rotavirus vaccine introduction in Mexico on child mortality rates. Mexico is obviously a much richer country than Malawi and South Africa, but rather sizable declines in mortality were observed. Rates of diarrhea related deaths reduced from 61.5 to 36.0 deaths per 100,000. While not all of this can be directly related to the vaccine, it is notable and incredibly good news as I would see this as a lower bound of what might be expected in poorer countries.

So overall, really promising news on the rotavirus front – there should be no reason to hold back plans to roll this vaccine out in the poorest countries as soon as possible. But lots more attention needs to be given to the additional challenges of delivery this particular vaccine. Good thing Bill Gates has doubled his commitments to childhood immunizations…I know how I would spend some of that big chunk of change.